The Mindful Way through Depression

Freeing Yourself from Chronic Unhappiness

The Guilford Press

Contents

"Oh No, Here I Go Again" Why Unhappiness Won't Let Go

Alice tossed and turned. She couldn't sleep. It was 3:00 in the morning, and she'd awakened with a jolt two hours earlier, her mind instantly buzzing with a rerun of the afternoon meeting with her supervisor. This time, though, there was a commentator. It was her own voice, chiding her with shrill questions:

"Why did I have to put it that way? I sounded like an idiot. What did he mean by 'satisfactory'—okay, but not nearly good enough for a raise? Kristin's department? What do they have to do with the project? That's my territory ... at least for now. Is that what he meant by evaluating how things go? He's planning to put someone else in charge, isn't he? I knew my work wasn't good enough—not for a raise and maybe not even to keep my job. If only I'd seen it coming.... "

Alice couldn't get back to sleep. By the time her alarm went off, her thoughts had moved on, from the hopelessness of her position at work to the dire straits she and the children would be in once she was out looking for a job again. As she wrenched her aching body out of bed and struggled toward the bathroom, she was already picturing herself being rejected by one new prospective employer after another.

"I can't blame them. I just can't understand why I feel so down so often. Why do I get so overwhelmed by everything? Everyone else seems to manage fine. I obviously don't have what it takes to cope with both a job and a home. What was it that he said about me?"

The tape loop in her head started over again.

Jim hadn't had any trouble sleeping. In fact, he just seemed to have a hard time being awake. There he was again, sitting in his car in the office parking lot, feeling the sheer weight of the day pinning him to his seat. His whole body felt leaden. It was all he could do just to unlatch his seat belt. And still he sat, immobile, stuck, unable to grab the door handle and just go to work.

Maybe if he mentally ran through his schedule for the day ... that always got him moving, started the ball rolling. But not today. Every appointment, every meeting, each phone call he had to return made him swallow what felt like an iron ball, and, with each swallow, his mind wandered away from the day's agenda to the nagging question that seemed to be with him every morning:

"Why do I feel so bad? I've got everything most men could ask for—a loving wife, great kids, a secure job, a nice house.... What's wrong with me? Why can't I pull myself together? And why is it always this way? Wendy and the kids are sick to death of my feeling sorry for myself. They are not going to be able to put up with me much longer. If I could figure it out, things would be different. If I knew why I felt so rotten, I know I could solve the problem and just get on with life like everyone else. This is really stupid."

Alice and Jim just want to be happy. Alice will tell you she's had good times in her life. But they never seem to last. Something sends her into a tailspin, and events she would have shaken off when younger now seem to plunge her into despair before she knows what's hit her. Jim says he's had good times too—but he tends to describe them as periods marked more by the absence of pain than by the presence of joy. He has no idea what makes the dull ache recede or return. All he knows is that he can't put his finger on the last time he spent an evening laughing and joking with family or friends.

As visions of being unemployed swirl through Alice's head, a deep fear of being unable to do what she needs to do for herself and her kids lurks around the edges of her mind. Not again, she thinks with a sigh. She remembers well what happened when she found out that Burt had been cheating on her and she kicked him out of the house. Naturally, Alice had felt sad and angry, but also humiliated by the way he had treated her. He had been unfaithful. She had wound up feeling that she had "lost" her battle to save the relationship. Then she felt trapped by her circumstances as a single mother. At first she had put up a good front for the sake of the children. Everyone was supportive, but there came a point when she thought that she should be over it by now. She couldn't continue to ask for help from family and friends. Four months later, she found herself feeling more and more tearful and depressed, losing interest in the children's choir she directed, unable to concentrate at work, and feeling guilty about what a "bad mother" she was. She couldn't sleep, she was eating "constantly," and eventually she went to her family physician, who diagnosed depression.

Alice's doctor prescribed an antidepressant, which made a big improvement in her mood. Within a couple of months she was back to her normal self—until nine months later, when she totaled her new car in an accident. She couldn't shake the feeling that she'd narrowly escaped death, even though she'd walked away with just a few bruises. She found herself repeatedly reviewing the accident, asking herself how she could possibly have been so reckless, how she could have exposed herself to a risk that might have robbed her kids of the only real parent they now had. As the dark thoughts got louder, she called her doctor for another prescription, and soon she felt better again. This pattern repeated itself a few more times over the next five years. Every time she noticed the signs of being pulled down into the vortex again, she felt increasing dread. Alice wasn't sure she could take it anymore.

Jim had never been diagnosed with depression—he had never even talked to his doctor about his bleak frame of mind or his persistently low moods. He was surviving, and everything in his life was fine; what right did he have to complain about it to anyone? He would just sit there in his car until something came to him that would move him to open that door and get going. He tried thinking about his garden and all the beautiful new tulips that would be sprouting up soon, but that just reminded him that he hadn't really done the fall cleanup adequately and he'd have a lot to do to get the yard ready now, a thought that exhausted him. He thought about his kids and his wife, but the idea of trying to participate in dinner conversation that night just made him want to go to bed early, as he had last night. He had planned to get up early to finish what he'd left on his desk yesterday, but he just couldn't seem to wake up. Maybe he would just stay at the office till he finished the thing once and for all, even if he had to be there till midnight....

Alice has recurrent major depressive disorder. Jim may suffer from dysthymia, a sort of low-grade depression that is more a chronic state than an acute condition. The diagnosis doesn't matter that much. The problem for Alice and Jim and many of the rest of us is that we want desperately to be happy but have no idea how to get there. Why do some of us end up feeling so low over and over? Why do some of us feel as if we're never really happy but just dragging ourselves through life, chronically down and discontented, tired and listless, with little interest in the things that used to give us pleasure and make life worthwhile?

For most of us, depression starts as a reaction to a tragedy or reversal in life. The events that are particularly likely to produce depression are losses, humiliations, and defeats that leave us feeling trapped by our circumstances. Alice became depressed following the loss of her long-term relationship with Burt. At first she was fueled by righteous indignation and tackled single-parenthood with a vengeance. But it was all she could do to take care of things on the home front when she returned from work at night, so she gave up post-work get-togethers with friends, dinner with her mother, and even phone calls to her sister in a nearby state. Soon she felt weighed down by loneliness, crushed by a constant sense of abandonment.

For Jim, the loss was a little more subtle and a lot less visible to the outside world. A few months after he received a promotion at his consulting firm, Jim found he no longer had time to spend with friends and had to drop out of his gardening club because he was staying later and later at the office. He also realized he didn't actually enjoy his new supervisory role. Eventually he asked to return to a job similar to the one he had done before. The change was a relief, and no one knew Jim wasn't happy—not even Jim at first. But he started getting spacey and seemed often distracted. In his head, Jim was second-guessing his decision, overanalyzing every brief interaction with his bosses, and ultimately chiding himself over and over for having "failed" his company and himself. He said nothing and tried to ignore these thoughts, but over the next five years he withdrew more and more, had a lot of minor health complaints, and, in the words of his wife, "just wasn't the man I used to know."

Loss is an unavoidable part of the human condition. Most of us find life an enormous struggle after the sort of crisis that Alice went through, and many of us feel diminished by disappointments in ourselves or others, as Jim did. But embedded in Alice's and Jim's stories are clues to why only some of us suffer lasting effects from such difficult experiences.

WHEN UNHAPPINESS TURNS INTO DEPRESSION ... AND DEPRESSION WON'T GO AWAY

Depression is a huge burden affecting millions today and becoming more common in Western countries, as well as in developing countries that are "Westernizing" their economies. Forty years ago depression struck people first, on average, in their 40s and 50s; today it's their mid-20s. Other statistics in the box on page 16 show the scope of the problem today, but none may be more alarming than the data showing that depression tends to return. At least fifty percent of those experiencing depression find that it comes back, despite the fact that they appeared to have made a full recovery. After a second or third episode, the risk of recurrence rises to between eighty and ninety percent. People who first became depressed before they were twenty years of age are at particularly high risk for becoming depressed again. What's going on here? As psychologists who had been involved in treating and researching depression for many years, three of us (Mark Williams, Zindel Segal, and John Teasdale) wanted to find out. The rest of this chapter, plus Chapter 2, explains what science has learned about the nature of depression and unhappiness and how that knowledge, once we banded together with our fourth author (Jon Kabat-Zinn), ultimately produced the treatment on which this book is based.

One of the most critical facts we learned was that there is a difference between those of us who have experienced an episode of depression and those who have not: depression forges a connection in the brain between sad mood and negative thoughts, so that even normal sadness can reawaken major negative thoughts. This insight added a new dimension to our understanding of how depression works. Decades ago pioneering scientists like Aaron Beck had the insight that negative thoughts play a leading role in depression. Beck and his colleagues made a huge leap in our understanding of depression when they found that mood was strongly shaped by thoughts—that it wasn't necessarily events themselves that drove our emotions but our beliefs about or interpretations of those events. Now we know there is much more to the story. Not only can thoughts affect mood, but in those of us who get depressed, mood can affect thoughts in ways that can then make an already low mood even lower. It doesn't require a traumatic loss for those of us who are vulnerable to plunge down into the spiral again; even the kinds of everyday difficulties that many people shrug off can start the descent into depression or perpetuate unhappiness from day to day. Even more, as we'll see, this connection becomes so ingrained that sometimes the negative thoughts that lead to depression can be triggered by sadness so fleeting or minimal that the person experiencing it is hardly aware of it.

No wonder so many of us feel we can't pull ourselves out of the abyss, no matter how hard we try. We have no idea where the descent began.

Unfortunately, our valiant efforts to figure out how we got where we are turn out to be part of a complicated mechanism by which we get dragged down even farther. The way in which our efforts to understand ourselves can lead to additional problems instead of solutions is a complex story. It starts with a fundamental knowledge of the anatomy of depression and of its four key dimensions: feelings, thoughts, body sensations, and behaviors, through which we respond to the events of life. Key to this understanding is how these different dimensions interact.

THE ANATOMY OF DEPRESSION

Let's look briefly at the development of the whole pattern of depression before we get into its individual elements.

When we become deeply unhappy or depressed, an avalanche of feelings, thoughts, physical sensations, and behaviors comes into play, as revealed in the checklist of the hallmark symptoms of major depression (see box, p. 19). The huge emotional upheaval that can come from experiencing loss, separation, rejection, or any reversal that brings a sense of humiliation or defeat is normal. Disturbing emotions are an important part of life. They signal to us and to others that we are severely distressed, that something untoward has happened in our lives. But sadness can give way to depression when the sadness turns into endemically harsh negative thoughts and feelings. This morass of negative thinking then generates tension, aches, pains, fatigue, and turmoil. These, in turn, feed more negative thinking; the depression gets worse and worse and, with it, the hurt. We only compound our feelings of depletion if we deal with them by giving up activities that normally nourish us, like getting together with friends and family who might be a real support for us. Our exhaustion is compounded if we deal with it by simply working harder.

It's not difficult to see how feelings, thoughts, physical sensations, and behaviors are all part of depression. Earlier in this chapter we described the aches that Alice felt after a night of berating herself, the "iron ball" that Jim felt like he had to keep swallowing when he thought about what his day held in store. As many of us are only too aware, being "down" can make it hard to do much of anything or to make choices that get us where we want to go. What's harder to see is how any one part of this anatomy can trigger the downward spiral and then how each component feeds into and reinforces the others. By this process the state of mind that keeps us unhappy or leaves us vulnerable to depression gets stronger and stronger. A closer look at the parts at this point may help us see the whole more clearly.

Feelings

If you think back to the last time you began to feel unhappy and describe your feelings, many different words might come to mind: sad, blue, downhearted, miserable, despondent, low, feeling sorry for yourself. The strength of such feelings can vary; for example, we can feel anywhere from slightly sad to extremely sad. It's normal for emotions to come and go, but it is rare for such depressive feelings to occur by themselves. They often cluster with anxiety and fear, anger and irritability, hopelessness and despair. Irritability is a particularly common symptom of depression; when down, we may feel impatient, at the end of our rope with many of the people in our lives. We may be more prone than usual to angry outbursts. For some, especially young people, irritability is a more prominent experience than sadness in depression.

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The feelings by which we generally define depression are usually thought of as an end point. We're depressed; we feel sad, low, blue, miserable, despondent, desperate. But they're also a starting point: research has shown that the more we've been depressed in the past, the more sad mood will also bring with it feelings of low self-esteem and self-blame. Not only do we feel sad, we may also feel like failures, useless, unlovable, losers. These feelings trigger powerful self-critical thoughts: we turn on ourselves, perhaps berating ourselves for the emotion we are experiencing: This is dumb, why can't I just get over this and move on? And, of course, thinking this way just drags us down further.